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Opportunity Assessment for Prospective Agents 		Progress:  1  2  3  4   
Interested in representing American Modern Insurance Group? Please fill in the brief Opportunity Assessment worksheet below to understand how your agency can partner with American Modern.

Fields marked with a * are required for submission
Agency Information
Agency Name:  *
Years in Business: 
Street Address:  *
City:  *
State:   *
Zip Code:  *
Contact Name:  *
Title: 
Telephone:  (  ) -  *
E-mail Address:  * For internal purposes only
Agency's Total Annual Premium - Personal Lines:  $ 
Agency's Total Annual Premium - Commercial Lines:  $ 
How many states does your agency write in? 
How many branch offices does your agency have? 
Does your agency currently write with American Modern?  Yes      No
 
 
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Last Updated on December 10, 2004